There is a temptation in health science ethics educations to make it doable, tidy, and free of much controversy. But sidestepping contentious issues and their relationship with related topics, like diversity, health equity, and religious differences,Footnote 1, Footnote 2 and merely reciting last year’s polite power point slideshow on informed consent, autonomy, or the reasonable person standard, is no longer sufficient. Vexing and contentious social issues do and will continue to arise in the health sciences ethics classroom. And, when they do, acknowledging and engaging them, however risky, is worthwhile and can enhance the delivery of existing competencies.Footnote 3 Here is why and how to make that work.
Ethics education is risky
January 7, 2021, a faculty course director decides to have a moment of silence and reflection about the events of January 6 during a third year online medical school ethics course. In those few minutes concern and lament are expressed by many students and the course director offers to debrief further outside of class. The course director was reported to the dean for being biased and was dismissed from her duties without explanation and recourse.
Ethics teachers face dilemmas like these frequently. And, answers are not clear. On one level, the events of January 6, 2021, were not central to the specific content of healthcare ethics learning. The course director could have ignored them. Yet some moments deserve at least acknowledgement lest the instructor appear tone deaf. By our lights, at least acknowledging vexing social issues in class should be within bounds for ethics teachers and can demonstrate an instructor’s humanity and engender learning. Beyond that, students or faculty will raise contemporary issues like poverty, gun violence, or care for immigrants.
The wisdom of whether and when to wade into contentious topics and the moral diversity they uncover is a hindsight luxury. Those decisions often must be made in the moment in the face of unfolding events, conversations, and perceived learner needs. And many times, it is worth that risk even if doing so risks being perceived as taking a political stance. Here is why.
Engaging contentious issues is worth it
Divergent views regarding contentious social issues swirl in society and make their way into the lecture halls and wards. Racism, income inequality, bigotry, polarization, reproductive rights, “fake news,” gun violence, and mistrust all show up in health sciences education spaces. And, concerned students bring their concern to their professional education. Engaging contentious social issues in ethics class has value for several reasons.
It motivates students
Many students draw professional motivation from concern for social justice issues. For these, ethics class becomes the closest curricular point of intersection with their social justice orientation. It is hard to imagine that quashing or ignoring that interest serves the future of health sciences. Doing so may alienate passionate students if faculty are not willing or able to engage those topics in ethics coursework.
It enhances ethics-related competencies
Ethics competencies outlined in the Romanell Report include sensitivity and responsiveness to others, interprofessional collaboration, as well as flexibility and maturity,Footnote 4 which require practice to demonstrate. Health sciences learners can bring polarized positions and identity politics to professional school. Their education must attend to diversity in backgrounds, cultures, opportunities, identities, beliefs, and perspectives,Footnote 5 as well as attention to medicine’s own culture.Footnote 6 Examining arguments for and against (for instance) the role of healthcare in climate change, the limits of patient choice, or differing conceptions of human flourishing, are worth broaching even if they spawn conflict or feel risky.Footnote 7
Doing so provides practical material for productive engagement across difference, inviting learners to practice courageous listening necessary in future training and practice. Engaging with different perspectives can moderate extreme perspectivesFootnote 8 and can promote adaptive behaviors essential for teamwork and humility, like deep listening and mutual understanding.Footnote 9 Rather than presuming consensus,Footnote 10 ethics education must offer teacher and learner alike deeper engagement that differentiates people from ideas, tests students’ and faculties’ convictions, while acknowledging the limits of what can be proven.
Here is how to do it
The best way to engage contentious social issues in health sciences ethics education is to build constructive, growth-oriented learning environments that deprioritize risk-avoidanceFootnote 11, Footnote 12, Footnote 13 and that instead introduce students and faculty alike to the moral traditions on which deep differences rest,Footnote 14 while modeling the kind of humility, curiosity, and trust crucial for finding common ground.Footnote 15
Psychological safety means candor
Such a learning environment is at the core of psychological safety which engenders honest questions, inclusive idea expression, and challenging the status quo.Footnote 16, Footnote 17 This fits ethics education. Silencing or stigmatizing others’ unfashionable positions has no place in the work of ethics nor is it consistent with psychological safety’s goal—candor.
Unfortunately, focusing on learners “feeling safe” stunts growth and needed candor. Yes, students from minoritized backgrounds should have voice so that everyone is challenged charitably, listens courageously, and disagrees productively.Footnote 18 Yet, challenging and uncomfortable experiences in ethics class, as in many clinical rotations, can spur growth if we let them. And, we must. Expunging discomfort from the classroom fails to instill a deeper authenticity and openness to change that is so crucial for teamwork.
Tools and tactics
Diversity-cognizant and conflict-responsive health sciences ethics education can be supported in several ways.
1. Forecast risk
Syllabi and introductory remarks can and should forecast the risky nature of doing ethics and necessity of encountering uncomfortable topics and diverse opinions. Trigger warnings will not suffice.Footnote 19 We need “courageous spaces” full of vulnerability, curiosity, and mutual regard.
2. Model diversity acknowledging, debriefing, and addressing
Of course, taking diversity seriously involves representing a range of speakers/teachers, topics, positions, backgrounds, readings, and cultures, including faculty with controversial or unpopular positions. Modeling charitability and responsiveness, while tolerating discomfort, can help learners feel what it is like to work in a pluralistic environment where competencies must be translated into measurable behaviors.Footnote 20
Small group faculty must be trained to cultivate and model curiosity, openness, and courageous conversation. Three behaviors may help. Acknowledging is a basic form for naming difficult social issues that arise. Debriefing offers an additional level of engagement, often outside the classroom. Addressing represents a moment when faculty choose to take up a controversial topic and model how to talk about normative differences with an opinionated future team member. Judgment calls in whether and how to do this will abound. Is the timing right? Is this context conducive to mutual understanding? We cannot answer all those questions; they are inherently contextual and prudential. But avoiding all those opportunities is antithetical to psychological safety. Much better to practice candid courageous conversations in small groups than propagate a malignant cone of silence and avoidance that would hamper learners’ growth and valued team members.
3. Articulate core values and purpose
Ethics teaching should first enhance understanding—not win arguments—which requires core dispositional values like humility, curiosity, and reasoned discourse. Charitable disagreement is its own worthy goal of ethics class. Moving toward each other and fostering more substantive conversations cultivates imagination and empathy for others’ worlds—a crucial skill for today’s healthcare climate where power, hierarchies, and fear of dissent persist.
4. Set and enforce ground rules
Create conditions for candor, conviction, and curiosity, is not a license for bullying or bigotry. For instance, Woodruff et al.Footnote 21 outline six ground rule elements: seek meaningful discourse, listen carefully, speak respectfully, invite different perspectives, trust intent, and be true to self and generous to others. These shared norms will keep ethics class from devolving into a shouting match, name calling, or forum for personal attack, where reasoned discourse fizzles. Each person is valued and invited to contribute without fear of humiliation, ridicule, or rejection.
5. Create supportive structures and due process, not retribution and sanction
Fear of being “written up” can easily paralyze an ethics instructor’s work. Therefore, when (not if) complaints against faculty arise, due process structures should be in place to hear concerns of all involved without preemptive judgment or individual scapegoating. If content is triggering, those triggered need support and a listening ear. If someone (faculty or another student) is triggering, debriefing ought to occur without implied fault. In most circumstances, having supportive structures in place will mitigate or eliminate the need for most disciplinary actions. Each should be judged by their collegiality, not by their politics or positions. If, for instance, racist statements are made, due process will be tested. Some incidents may require independent adjudication. And, if participants (students or faculty) violate mutual respect policies, those policies can be invoked. And, no matter who the subject of concern, difficult decisions must be delivered in-person, face-to-face. Insensitive behavior should not be punished with insensitive bureaucratic procedure. Both faculty and students deserve such supports; without them, ethics education will suffer, and faculty numbers, quality, and morale will dwindle.
Inspired by core values translated into shared ground rules, ethics teaching can invite differing perspectives while engaging contentious social issues, even if it is uncomfortable or feels unsafe or out-of-scope. Such an approach offers a chance to instill psychological safety, acknowledge and live with difference, and prepare learners to live within the polarized and contentious social realities that will affect their lives and practice for decades to come.
Acknowledgments
The views expressed are those of the authors and do not necessarily represent the positions of their employer. A prior version of this paper was presented at the American Society for Bioethics and Humanities National Meeting, October 15, 2021. We thank Elizabeth M. Valencia, MD, for thoughtful reading and feedback on a prior draft and Christi Audeh for thoughtful edits.
Competing Interest
The authors report no competing financial relationships.
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